A nurse is assessing a client who has peripheral artery disease for potential safety concerns. Which of the following client statements should the nurse report to the provider?
"l need to walk slowly as I lose my balance often."
"l don't go out much because of the pain in my legs."
"It makes me sad that I can't keep up with my grandchildren."
"l have a small-healed area on my spine that is painful."
The Correct Answer is A
A. "I need to walk slowly as I lose my balance often": This statement indicates a potential safety concern related to balance issues while walking. Loss of balance can increase the risk of falls, especially in individuals with peripheral artery disease (PAD) who may already have compromised circulation and reduced sensation in their legs. The nurse should report this statement to the provider for further evaluation and intervention to prevent falls and promote safety.
B. "I don't go out much because of the pain in my legs" : While this statement suggests that the client experiences pain in their legs, it does not directly indicate a safety concern that requires immediate reporting to the provider. Pain management strategies may be discussed with the provider to address this issue.
C. "It makes me sad that I can't keep up with my grandchildren" : While this statement reflects emotional distress related to the client's inability to participate fully in activities with their grandchildren, it does not indicate a specific safety concern that requires reporting to the provider. However, addressing the client's emotional well-being is important for overall holistic care.
D. "I have a small-healed area on my spine that is painful" : This statement describes a painful area on the client's spine but does not directly relate to potential safety concerns associated with PAD. The nurse may further assess this issue and include it in the client's overall assessment, but it does not require immediate reporting to the provider for safety concerns related to PAD.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
A. Elevated erythrocyte sedimentation rate (ESR): Elevated ESR is commonly seen in inflammatory conditions such as pericarditis. ESR measures the rate at which red blood cells settle in a tube of blood over a certain period, and elevated levels indicate inflammation or tissue damage.
B. Increased C-reactive protein (CRP): CRP is an acute-phase reactant produced by the liver in response to inflammation. Elevated CRP levels are indicative of inflammation, making it a useful marker in pericarditis.
C. Elevated thyroid-stimulating hormone (TSH): Elevated TSH levels are not typically associated with pericarditis. TSH is a hormone produced by the pituitary gland that stimulates the thyroid gland to produce thyroid hormones. Elevated TSH levels are seen in conditions such as hypothyroidism.
D. Increased brain natriuretic peptide (BNP): BNP is a hormone produced by the heart in response to increased pressure and volume overload. Pericarditis can lead to increased pressure within the heart, resulting in elevated BNP levels. Therefore, increased BNP levels are anticipated in pericarditis.
E. Increased troponin I: Troponin I is a cardiac biomarker released into the bloodstream when there is damage to cardiac muscle cells. While pericarditis primarily involves inflammation of the pericardium (the sac surrounding the heart), severe cases can lead to myocardial involvement and subsequent release of troponin I. Therefore, increased troponin I levels may be observed in pericarditis, especially if there is myocardial involvement.
Correct Answer is B
Explanation
A. Encouraging increased mobility: While mobility is important for overall health, it may not be the primary lifestyle modification emphasized in the discharge teaching for heart failure. The focus is typically on dietary and fluid restrictions, medication adherence, and symptom management.
B. Dietary and fluid restrictions: Dietary and fluid restrictions are essential lifestyle modifications for managing heart failure. Clients are often advised to follow a low-sodium diet and restrict fluid intake to prevent fluid retention and exacerbation of heart failure symptoms.
C. Cessation of intravenous (IV) drug use: While cessation of intravenous drug use is important for overall health and may be addressed if relevant to the client's situation, it may not be a primary focus of discharge teaching specifically related to heart failure.
D. Cessation of hormonal supplements: Cessation of hormonal supplements may be recommended if they contribute to heart failure or exacerbate its symptoms. However, this recommendation would be specific to individual client circumstances and may not apply to all clients with heart failure.
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